Hemocompatibility and Long-Term Outcomes in HeartWare Versus HeartMate II Versus HeartMate 3: Multicenter Real-World Cohort.

BACKGROUND

To compare overall and hemocompatibility-related outcomes across third-generation centrifugal-flow HeartMate 3 (HM3) versus second-generation axial-flow HeartMate II (HMII) and centrifugal-flow HeartWare (HVAD) in routine clinical practice.

METHODS

We conducted a multicenter observational cohort of adult LVAD recipients (n = 327: HVAD n = 112, HMII n = 142, HM3 n = 73). Baseline characteristics and perioperative variables were recorded. Overall survival was analyzed using Kaplan-Meier and Cox proportional hazards models with HM3 as reference. Hemocompatibility-related adverse events (HRAE; pump thrombosis, ischemic stroke, major bleeding) were assessed with cumulative incidence functions (Aalen-Johansen) and Fine-Gray competing-risk regression with death as a competing event; the hemocompatibility score (HCS) summarized event burden over follow-up.

RESULTS

HM3 demonstrated superior long-term survival compared with both HMII and HVAD in Kaplan-Meier analyses (log-rank p < 0.001); this advantage persisted in multivariable Cox models. HRAE-free survival was also higher with HM3 on competing-risk analysis, driven by substantially lower pump thrombosis and fewer ischemic strokes relative to HMII and HVAD. Bleeding burden did not differ materially between devices, consistent with a class effect of continuous-flow support. LDH-based hemolysis markers and HCS distributions further favored HM3. Perioperative course and general postoperative complications were otherwise broadly comparable across devices.

CONCLUSIONS

In this real-world, multicenter cohort, HM3 was associated with better overall survival and a lower thromboembolic burden than HMII and HVAD, while bleeding risk remained similar. These findings support preferential selection of HM3 when device choice is feasible, and emphasize the need for targeted strategies to mitigate hemostatic complications across all LVADs.